ModifiedUnitedHealthcarePolicy CS103OH.C

Prolotherapy and Platelet Rich Plasma Therapies (for Ohio Only)

This Ohio-only medical policy governs coverage and medical necessity determination for prolotherapy and platelet-rich plasma (PRP) therapies for UnitedHealthcare members in Ohio.

Policy Summary

PayerUnitedHealthcare

PolicyProlotherapy and Platelet Rich Plasma Therapies (for Ohio Only)

Policy CodePolicy CS103OH.C

Change TypeClinical evidence and references updated

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization with documentation of diagnosis severity, prior conservative therapy failure, and specific PRP/prolotherapy preparation and treatment plan when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Updated Clinical Evidence and References sections to reflect the most current information

2therapies declared not medically necessary

Ohiopolicy jurisdiction

low-qualityevidence base described

5Applicable codes listed

1policy revisions recorded

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Coverage and Medical Necessity Determinations

UnitedHealthcare Coverage Rationale — summary statement of policy coverage stance and applicability.

Due to insufficient evidence of efficacy, the following are considered unproven and not medically necessary for any condition or indication: Prolotherapy; Platelet-rich plasma (PRP). This Medical Policy applies to the state of Ohio and, when evaluating requests for services stated as unproven or not medically necessary, Ohio Administrative Code 5160-101 and any applicable federal/state/contractual requirements must be followed. In the event of a conflict, federal/state/contractual requirements govern.

Providers should consult plan-specific benefit language and applicable prior authorization requirements. UnitedHealthcare reserves the right to modify Policies and Guidelines and uses InterQual® for primary criteria; where InterQual® is not applic able, UnitedHealthcare Medical Policies, Coverage Determination Guidelines, and Utilization Review Guidelines approved by the Ohio Department for Medicaid Services may be used.

Coverage considerations by indication

Coverage considerations by indication — evidence strength and policy implications for commonly evaluated clinical indications. These considerations consolidate evidence syntheses, guideline statements, and technology assessments.

Knee osteoarthritis (KOA): Evidence is mixed. Several meta-analyses and RCTs report short-term symptom improvement with PRP or dextrose prolotherapy in some trials, but high-quality, large RCTs (e.g., Bennell et al., 2021) and evidence syntheses note no consistent clinically meaningful benefit at 12 months for many preparations. Heterogeneity of PRP preparations, lack of standardization, variable injection protocols, and inconsistent long-term data limit routine coverage. Guideline positions (AAOS, ACR) and specialty society statements generally do not support routine use for advanced OA and in some cases recommend against PRP or prolotherapy for knee/hip OA. For these reasons, routine/unselected coverage of PRP or prolotherapy for KOA is not supported.

Soft-tissue tendinopathies and lateral epicondylosis: Evidence shows variable results. Systematic reviews and RCTs of DPT and PRP for lateral epicondylosis and other tendinopathies report some trials with clinically meaningful short-term improvements, but pooled evidence is inconsistent and overall certainty is low to moderate. For lateral epicondylosis (tennis elbow) and select refractory tendinopathies, some evidence suggests benefit at 12 weeks to 6 months; however, heterogeneity of study designs, small sample sizes, and uncertain long-term benefit limit broad coverage. Routine/unselected use of PRP or prolotherapy for tendinopathies is not supported; consideration for use may be limited to select cases refractory to standard conservative care within the context of documented clinical justification or research protocols.

Rotator cuff and other shoulder tendinopathies: Evidence is inconsistent. Systematic reviews report no clear advantage of prolotherapy over corticosteroids or other comparators for rotator cuff-related pain and function, and guideline statements do not support routine biological augmentation for rotator cuff repair. PRP/prolotherapy should not be routinely covered as first-line treatment or as routine surgical augmentation.

Coverage considerations — operational notes and common exclusions

Operational considerations and common exclusions — study-derived and policy-applicable factors to inform clinical review and utilization management.

Common clinical and trial exclusions noted in the evidence base that may be relevant to utilization review include: presence of joint effusion or infection; recent (typically within weeks to months) intra-articular corticosteroid or botulinum toxin injections; advanced radiographic OA (Kellgren-Lawrence grade 4) in many KOA trials; and concurrent peripheral arterial disease or factors impairing wound healing in wound studies.

PRP-specific operational issues: PRP preparations are heterogeneous and lack standardization (platelet concentration, leukocyte-rich vs leukocyte-poor, activation methods). Many trials lack detailed reporting of PRP composition. Long-term safety beyond one year is incompletely characterized. For these reasons, requests for PRP should include documentation of PRP preparation method, rationale for use, prior conservative therapies attempted, and anticipated treatment plan. Routine augmentation with PRP for meniscal repair or ACLR graft healing is not supported by the evidence.

Prolotherapy-specific operational issues: Prolotherapy protocols vary in dextrose concentration, injection targets (intra-articular vs peri-articular vs peritendinous), number and timing of injections, and use of imaging guidance. Evidence for prolotherapy is inconsistent across conditions; routine coverage is not supported. For certain refractory soft-tissue conditions (e.g., lateral epicondylosis), the literature suggests potential short-term benefit, but policy-based coverage requires documented failure of first-line conservative measures and clear clinical rationale.

Prior Authorization, Documentation, and Authorization Guidance

Prior Authorization

Prior authorization and medical necessity evaluation

Prior authorization and medical necessity evaluation — requests for unproven services (prolotherapy, PRP) will be evaluated using Ohio Administrative Code; federal/state/contractual requirements govern coverage decisions.

Documentation Required

Prior authorization: clinical baseline and treatment plan

Document clinical baseline and a clear treatment plan when seeking prior authorization: include diagnosis, disease severity (e.g., Kellgren-Lawrence grade for KOA), baseline patient-reported outcome scores (VAS, WOMAC, KOOS), objective measures where applicable, and planned interval assessments to demonstrate response.

Baseline diagnosis and severity (e.g., KL grade for KOA)
Baseline PROs: VAS, WOMAC, KOOS, SPADI, DASH as appropriate
Planned treatment frequency/timing and objective follow-up measures

Applicable Procedure and Billing Codes

Applicable Codes (reference)mixed

0232T	Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed
G0460	Autologous platelet rich plasma (PRP) or other blood-derived product for nondiabetic chronic wounds/ulcers (includes, as applicable: administration, dressings, phlebotomy, centrifugation or mixing, and all other preparatory procedures, per treatment)
G0465	Autologous platelet rich plasma (PRP) or other blood-derived product for diabetic chronic wounds/ulcers, using an FDA-cleared device for this indication (includes as applicable: administration, dressings, phlebotomy, centrifugation or mixing, and all other preparatory procedures, per treatment)
M0076	Prolotherapy
P9020	Platelet-rich plasma, each unit

Definitions and Background on Therapies

Prolotherapy (also called proliferative therapy) involves injection of substances such as dextrose, saline, sarapin, or local anesthetics (e.g., procaine or lidocaine) into ligaments, tendons, or periarticular tissues with the intent to provoke a local inflammatory or reparative response and stimulate tissue healing or strengthen connective tissues.

Prolotherapy definition (inv-71)

DefinitionInjection of substances (e.g., dextrose, saline, sarapin, procaine, or lidocaine) directed to injured ligaments, tendons, or periarticular tissues to stimulate a mild inflammatory healing response intended to promote new tissue growth and strengthen the weakened structure.

Alternate names / scopeAlso called proliferative therapy or regenerative joint injection; may include growth factor injection, growth factor stimulation, or inflammatory prolotherapy techniques.

MechanismProduces a mild local inflammatory response that encourages formation of new ligament or tendon fibers, leading to gradual tissue strengthening with repeated treatments.

Common agentsHypertonic dextrose is most used; other injectates include saline, sarapin, procaine, lidocaine, and sometimes PRP or autologous stem cell sources.

Policy Updates and Revision Notes

2026-03-01policy_revisionLatest

Policy version CS103OH.C became effective; Clinical Evidence and References sections were updated and the previous version CS103OH.B was archived.

Policy Summary

PayerUnitedHealthcare

PolicyProlotherapy and Platelet Rich Plasma Therapies (for Ohio Only)

Policy CodePolicy CS103OH.C

Change TypeClinical evidence and references updated

Effective DateMar 1, 2026

Next Review DateN/A

SourceLink

On This Page

Lower-limb tendinopathies (Achilles, plantar fasciitis): Systematic reviews and technology assessments report limited or inconclusive evidence for PRP and prolotherapy. For plantar fasciitis, some trials suggest PRP may be superior to corticosteroids in certain outcomes, but evidence quality is low and heterogeneity is high. For Achilles tendinopathy, pooled data are inconclusive. Routine coverage is not supported; select refractory cases may be considered only with strong documentation and when other evidence-based therapies have failed.

Temporomandibular joint disorders (TMJ): Systematic reviews and small RCTs indicate some short-term benefit of hypertonic dextrose prolotherapy for TMJ pain and mouth opening compared with placebo, but studies are small and risk of bias is present. Evidence is insufficient to support routine coverage; use within clinical trials or with rigorous documentation may be considered.

Low back pain and intradiscal or facet/SIJ indications: Evidence for PRP or prolotherapy in discogenic or facet/SIJ pain is limited and heterogeneous. Small RCTs and prospective studies report mixed short-term benefits for select populations, but overall evidence quality is low. Routine coverage for low back pain indications is not supported.

Surgical adjuncts and orthopedics (meniscal repair, ACLR, arthroscopic procedures): Evidence does not consistently support routine use of PRP as an augmentation to improve graft healing or surgical outcomes; available data are heterogeneous and generally low certainty. Routine use as an operative adjunct is not supported.

Wound care (diabetic foot ulcers, venous leg ulcers, pressure ulcers, surgical wounds): Systematic reviews and technology assessments suggest PRP may improve healing rates for some diabetic foot ulcers and increase complete wound closure in selected trials, but study heterogeneity, variable PRP preparations, and inconsistent reporting of adverse events limit definitive conclusions. For venous and pressure ulcers evidence is insufficient. Routine coverage is not supported; PRP for wound care may be considered selectively when adjunctive therapy is used for hard-to-heal DFUs that have failed standard wound care, consistent with clinical evidence, local contractual rules, and when documented in the medical record or within approved research protocols.

Other indications (hip OA, foot/ankle osteochondral lesions, carpal tunnel, etc.): Evidence is limited, inconsistent, or of low quality. For hip OA, small trials and reviews show potential but unproven benefit; routine coverage is not supported. For other musculoskeletal and soft tissue indications, routine coverage is not supported outside investigational or research settings.

Wound care: For diabetic foot ulcers and select chronic lower-extremity wounds, some evidence supports adjunctive PRP in hard-to-heal DFUs; however, study heterogeneity and variable application methods limit generalizability. When considered, PRP use should follow best-practice wound care protocols and be documented as adjunct to standard care; inpatient use of autologous PRP gel for diabetic foot problems is not recommended outside clinical trials per some guidance (NICE).

Billing, prior authorization and documentation: Providers seeking coverage should submit: indication with clinical history, prior conservative treatments and durations, imaging and severity grading (when applicable), PRP preparation details (if applicable), proposed injection protocol (site, number of injections, timing), and rationale for deviation from guideline-based care. UnitedHealthcare may require prior authorization and may deny services lacking adequate documentation or not meeting policy/contractual criteria.

Research and special arrangements: Where evidence is uncertain but promising, interventions may be considered within approved clinical trials or registries with appropriate clinical governance, informed consent, audit, and outcome measurement. NICE recommends special arrangements or research-only use in settings where evidence quality is low; similar considerations may apply when payers evaluate exceptional coverage requests.

Prior Authorization

PRP for KOA — prior authorization guidance

PRP for knee osteoarthritis (KOA): prior authorization guidance — because PRP preparations are heterogeneous and evidence is mixed (including recent large RCTs showing no benefit), authorization should require documentation of prior conservative therapies attempted, clear indication, and detailed PRP preparation/administration parameters.

Document prior conservative care (exercise, weight loss, NSAIDs, PT, intra-articular corticosteroid or HA where appropriate)
Specify PRP preparation: leukocyte status, platelet concentration (if available), volume, activator use
Specify injection technique, number and timing of injections, and imaging guidance used

Prior Authorization

Prior authorization suggested for PRP for tendinopathies

Prior authorization suggested for PRP for tendinopathies — authorization may require documentation of failed conservative therapy (e.g., structured rehab, activity modification, NSAIDs, corticosteroid when indicated) and baseline functional/pain measures (DASH, SPADI, VAS, grip strength or tendon imaging when available).

Document conservative therapy attempts and duration
Provide baseline functional scores (DASH, SPADI) and pain VAS
Detail PRP protocol (preparation, dose, number of injections)

Denial Risk

Evidence quality may trigger coverage denial

Evidence quality may trigger coverage denial — small sample sizes, short follow-up, inconsistent reporting, and heterogeneous PRP/prolotherapy protocols increase the risk of denial when claim documentation does not address these limitations.

Requests relying on low-quality, small, or heterogeneous studies without robust, condition-specific supporting data may be denied
Provide long-term outcomes and standardized measures where available to mitigate denial risk

Note

Authorization context

Authorization context — this policy notes no exhaustive list of authorization triggers; clinical limitations and insufficient evidence will inform determinations. UnitedHealthcare uses InterQual and Medical Policies/Coverage Determination Guidelines; if InterQual lacks criteria, other approved guidelines may be used.

Check InterQual first; if not applicable, reference UnitedHealthcare Medical Policies or Coverage Determination Guidelines
Clinical rationale for request must address evidence gaps and patient-specific factors

Denial Risk

PRP for KOA — negative large RCT

PRP for KOA — negative large RCT impact on authorization: a high-quality, multicenter RCT (Bennell et al., 2021; n=288) found no difference between leukocyte-poor PRP and saline for pain or cartilage volume at 12 months. This trial may strongly influence denials when similar PRP preparations and indications are proposed.

When the proposed PRP preparation matches that studied (e.g., leukocyte-poor, 3 injections), expect reviewers to weigh Bennell et al. heavily
Provide compelling, preparation-specific evidence or rationale if requesting coverage contrary to this trial's findings

Documentation Required

Small, heterogeneous trials and lack of standardization

Small, heterogeneous trials and lack of standardized preparations — many studies vary in PRP composition, preparation, application, and outcome reporting; authorization should require specification of PRP composition (platelet/WBC counts if available), processing method, and rationale for chosen protocol.

Document platelet and WBC counts, centrifugation protocol, activators, and volume per injection
If counts are unavailable, provide vendor/kit details and standard operating procedure used

Denial Risk

Complication risk may influence authorization

Complication risk may influence authorization — some meta-analyses and trials report higher rates of transient post-injection pain and, in limited instances, severe pain requiring intervention. Documented safety concerns in specific anatomic sites (e.g., foot/ankle) should be addressed in authorization requests.

Include anticipated adverse events and monitoring plan in authorization request
For foot/ankle indications, disclose higher reported post-injection pain rates and any plan to mitigate/manage complications

Denial Risk

Heterogeneous evidence may limit coverage

Heterogeneous evidence may limit coverage — variability in study designs, patient selection, comparator treatments, and outcome measures reduces certainty of benefit; authorization should demonstrate patient-specific likelihood of benefit and prior treatment failures.

Provide prior treatment history and rationale for why PRP/prolotherapy is likely to benefit this patient despite heterogeneous evidence
Attach condition-specific literature supporting use of the exact preparation proposed

Denial Risk

Evidence and quality limitations

Evidence and quality limitations — methodological flaws, risk of bias, inconsistent AE reporting, and short follow-up dominate the literature. Requests should address these limitations with high-quality supporting data or enrollment in approved research/registry when applicable.

Cite high-quality, condition- and preparation-specific RCTs when available
Consider proposing treatment within a research protocol or registry if evidence is limited

Note

State/Contractual Requirements May Govern

State/Contractual Requirements May Govern — always check federal, state (Ohio Administrative Code), or specific contract terms first; if those requirements conflict with this policy, the federal/state/contract terms govern.

Verify Ohio OAC and member-specific contract terms before submitting authorization
In case of conflict, apply the governing federal/state/contract requirement

Documentation Required

Required clinical documentation to support medical necessity

Required clinical documentation to support medical necessity — include validated baseline and interval outcome measures (e.g., WOMAC, VAS, KOOS for KOA; DASH, SPADI, grip strength for upper-extremity; MIO and pain VAS for TMJ), imaging and classification (e.g., KL grade), prior conservative care records, and detailed PRP/prolotherapy preparation and administration notes.

Diagnosis, disease severity/classification (e.g., KL grade for KOA)
Baseline and follow-up PROs: VAS, WOMAC, KOOS, DASH, SPADI as appropriate
Objective measures: grip strength, MIO, imaging reports where applicable
Documentation of conservative care tried and response

Documentation Required